True fact: I failed out/dropped out of grad school in mathematics. But despite having little enthusiasm for topology or complex analysis, nothing drives me more nuts than people who say stuff like â€œIâ€™m not good at math â€“ just not a math person, I guess.â€ This attitude is not just incorrect, itâ€™s harmful. Most mathematics is quite straight-forward, if you practice and study conscientiously. Same with ECGs.

Stratford EMS was called for a (quite) elderly woman who wasnâ€™t feeling well. And of course, she lived on the 5th floor of a building with narrow, twisting stairs. Nonetheless, the paramedic Jay and his crew humped all their gear, including the Like-Pak, up those stairs. Good thing too.

There was a small language barrier, but Jay ascertained that the woman was complaining of a â€œburningâ€ in her epigastrium that she also felt in her back. This had started within the last hour. VS were normal, as was the exam, except that she â€œdidnâ€™t look right.â€ Time for the 12-lead!

Does it meet STEMI criteria? Thereâ€™s a bunch of ST segment depression in the inferior and lateral leads, but (as you all know) that doesnâ€™t usually count for field activation. There is ST segment in aVL, but it is < 1mm, and aVR shows only minor STE, while lead I shows none.

V2 and V3 show some STE, but it isnâ€™t much, and it would have been easy for Jay to tell himself that, since the computer didnâ€™t â€œseeâ€ it, it wasnâ€™t really there. Instead, he turned his attention to V4â€¦.

â€¦ and noted that the T wave seemed pretty darn tall, relative to the R wave. Along with a hint of STD in V3, it triggered Jay to consider a de Winter-ish pattern.

http://lifeinthefastlane.com/ecg-library/de-winters-t-waves/

The strict de Winter criteria require more ST depression, however, at least 1 mm, and we already have minor (but significant) anterior STE, so this ECG isnâ€™t a â€œpureâ€ example. However the morphology of V4 is pretty similar to that seem in a number of cases that Dr. de Winter evaluated, and who all turned out to have proximal LAD occlusions:

From http://dare.uva.nl/document/2/90500

This pattern convinced Jay to call this in as a STEMI, activating the cath lab from the field. To be specific, activating it from the 5th-floor back bedroom.

Good thing too â€“ it was â€œafter-hours,â€ and the cardiology team needed time to get in to the lab form home. Also, extrication turned out to be a flail, squeezing the patient down narrow, winding stairs.

A second ECG obtained 10 minutes later, during the perilous descent to the rig:

The computer still doesnâ€™t get it, but the ST segments in both lead I and V3 have started to straighten and move up, suggesting that the first diagonal is occluded, likely because the proximal LAD is blocked.

The Life-Pak finally made the call 15 minutes after the initial ECG. By this time, however, the patient was starting to look a lot worse, and the pressure was dropping. A fluid bolus was given, keeping the SBP barely above 90.

By the time the rig was pulling into the ED, 30 minutes after the initial ECG, the 12-lead wouldnâ€™t have been missed by an EMT-B student during their ED observation time. At this point, however, the patient was in frank cardiogenic shock, and the Stratford EMS team was directed to bypass the ED, since they had given the cath team sufficient heads-up to prep the lab. Without the “bedroom-activation” that Jay made, this patient could have arrested while waiting in the ED.

Lessons:Bring your gear in on every call. Every call.
Navy SEALS donâ€™t leave their gear behind while they â€œjust go check it out first,â€ and neither should EMS. A paramedic without their gear, and especially without their monitor/defib, is not that helpful.

Get serial ECGs when you suspect something.

Donâ€™t be satisfied if the computer â€œdidnâ€™t say there was a STEMI.â€

Practice, practice, practice your ECG skills! Jay felt comfortable committing to the early activation because he has worked hard at reading 12-leads, seeking feedback, and pushing his skills. He has developed a “gut sense” after hours of study, and hundreds of ECGs. He hasnâ€™t been afraid to ask questions, accept criticism, and learn.

Turn off the interpretation. Makes people lazy and you will miss it. If we are to be taken seriously in the medical profession we need to stop taking the easy way. If that’s the way you interpret 12-leads your not treating your patient.

I need help. I’m an RN and I have tried and tried and tried to learn how to read 12 leads accurately. It’s just not clicking. I’ve read two different manuals, looked at several different websites, and practiced till I’m blue but I need something else. Can anyone recommend a good bare bones EKG training system or literature for the EKG challenged like me??

Well this blog is a great place to start! We cover most every aspect of emergency electrocardiography, with a variety of authors, and multiple perspectives, usually in a clinical context.

If it is a book you are looking for, I prefer Ken Grauer’s. I started with Dr Grauer as a paramedic student and I still re-read his books now. In addition, he has been generous with his teaching pearls through the EKG Club page on Facebook.

Ken Grauer58 Year Old Male, Workout Worry@ Eli — I don’t see AFlutter. That is, I see no indication of regular atrial activity at a rate consistent with AFlutter. Instead, the rhythm is irregularly irregular without P waves = AFib at a controlled ventricular response. In my opinion, one doesn’t need Sgarbossa criteria here to activate the cath lab. So, yes the…
2018-09-13 02:09:24

Vince DiGiulioIs epinephrine harmful in cardiogenic shock?Sorry about that; I copied the quote from the article and my browser automatically changed the "μ" to an "m". Thanks for noticing, and thanks for pointing it out in the most passive-aggressive manner possible.
2018-09-12 16:45:26

Ken Grauer, MDElectrocardiographically Silent High Lateral STEMI EquivalentHi Tom. This is a great case — so NICE that you posted it for others to learned from. But as I commented several times when you sent this case around to our group — the T waves in V2,V3 are disproportionately peaked and transition occurs early (between V1-to-V2) — so the chest leads are NOT…
2018-08-14 08:38:03

Eli58 Year Old Male, Workout WorryAnybody else see the possibility of a LBBB or A-Flutter? I'm not sure if this will make any difference with the treatments but im just trying to interpret it first because if there is a LBBB then it does not meat Sgarbossa criteria and if it is A-Flutter that could explain the hyper acute T's…
2018-07-20 21:29:21